WQ0045901_Hayworth_Wesleyan_Church_Gymnasium_Addition_FTSSE_App_20241023

flm
Environri::
Received -
OCT 2 3 2024
State of North Carolina
Department of Environmental Quality
Division of Water Resources
VVinston-Saiem FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Worker Resources FTA 10-23 & SUPPORTING DOCUMENTATION
ional0ifce
Application Number: � T 6'q 6 ' (to be completed by DwR)
All items must be completed or the application will be returned
L APPLICANT INFORMATION:
1. Applicant's name: Hayworth Memorial Wesleyan Church (company, municipality, HOA, utility, etc.)
2. Applicant type: ® Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Brian Matherlee per 15A NCAC 02T .0106(b)
Title: Lead Pastor
4. Applicant's mailing address: 1626 Westchester Drive
City: High Point State: NC Zip: 27262-_
5. Applicant's contact information:
Phone number: [phone] Email Address: [e-mail]
It. PROJECT INFORMATION:
I . Project name: Hayworth Wesleyan Church - Gymnasium Addition
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project ❑ ARPA funded
If a modification, provide the existing permit number: W000 and issued date: ,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: W000_
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): fortitude: 35.949T Longitude;-80.0487-
5. Parcel ID (if applicable): 6890-31-8808 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Jesse W. Wilson License Number: 018197
Firm: Wilson Engineering Group
Mailing address: 1001 Chestnut Drive
City: Smithfield State: NC Zip: 27577-_
Phone number: 3(_36) 736-9267 Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Wesiside Wastewater Treatment Plant Permit Number: NCO024228
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ_
2. Downstream (Receiving) Sewer Information: 8 inch X Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00010
Owner Name(s): City of High Point
FORM: FTA 10-23 Page 1 of 5

Vl. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has -a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑. No Z N/A
2: If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No EDN/A
1 If the Applicant is a Home/Property Owners' Association, has an:HOA/POA Operational Agreement (FORM- HOA) and
supplementary documentation- as.requiredby I5ANCAC'`02T.0115(c.)'beenattached?
[:]Yes ❑ No n N/A
4. Origin of wastewater: (check all that apply):
® Residential'.(IndividuallyOwned) ❑`Retail (stores;. centers, malls) ❑ Car Wash
❑ Residential(I:eased) ❑.Retail with food preparation/service ❑ Hotel and/or Motels
Z School / preschool / day care El Medical / dental / veterinary facilities ❑. Swimming Pool/Clubhouse
❑ Food and drink facilities Church ❑ Swimming Pool/Filter Backwash.
❑ Businesses % offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 %Domestic. % Commercial %o Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there -a Pretreatment Program in effect? ❑ Yes No
6. Has a flow reduction been:approved under, 15A NCAC 02T .0114(f)? ❑ Yes ❑,No
Imes, provide a copy of flow reduction.approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type. (see 02T.0114(f))
Daily Design Flow a'b
No. of Units
Flow
Setiool
12 gal/day
1.27
1524 GPD
Church
5 gal/day
330
1650 GPD
Parsonage
120 gal/day
4
480 GPD
gal/
GPD.
ga]/
GPD
gal/
GPD
Total
3654 GPD
a See 15A NCAC 02T .0114(b): (d). (6)(,1) and (e)(2) for caveats to wastewater design. flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located. near high public use areas; and residential property
locatedsouth or east. of the Atlantic Intracoastal.. Waterway to be used as vacation rentals as defined in G.S. 42A-4).
b Per 15A NCAC 02T .6 14(c), design flow. rates for establishments not identified (in. table 15A NCAC 02T.0.114] shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and.other,measured data.
8 Wastewater generated by project: 3,04: GPD (per 1'5A NCAC 02T .0114 and G.S. W-215.1)
Do not incltide future flows or previously permitted allocations
If permitted flow is zero, please indicate -why:
❑ Pump' Station/Force Main or Gravity Sewer where flow will be perrnitted.in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ FIow hasalready been. allocated in Permit Number: Issuance Date:.
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 10-23 Page 2 of 5

VII. GRAVITY SEWER DESIGN" CRITERIA. (If Applicable) - 02T .0305'& MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
4
219
PVC
4
196
PVC
Section 'H & III of the MDC for Permitting,of Gravity. Sewers contains information, related to design criteria
➢ Section III contains information related'to minimum slopes for gravity sewer(s)
> Gversizmg linesto meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA:(If"Applicable) — 02T A305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF TRIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number:or name:
2. Approximate Coordinates (Decimal De -fees): Latitude: ° Longitude:
3_ Total number of pumps at the pump station:
3. Design flow of the pump station: trillions gallons per day (firm capacity)
3�- This should reflect the total GPM for the pump station with the.largestpump out of service.
4. Operational point(s) per pump(s): gallons per minute (GPM) at feet total,. dynamic,head
5. Summarize the force main to be permitted (for this Pump,Station):
Size.(inches) Length (feet) Material
If any portion of the force main is less than 4 inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.1.b.. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Pov&,er.reliability in accordance, with. l5A NCAC 02T .0305.(li)(11:
Standby power source or ❑ Standby pump
r Must have automatic activation and telemetry- 15A NCAC 02T.0305(h)(1)(B)_
Required for all pump stations with an average daily flow greater than or equal to 1.5,000 gallons per day
A Must be permanent.to facility and -may no;Cbepoi-table,
Or if the pump station has. an average daily flow less than 15,000gallons per day 15 A NCACO2T.0305(h)(1)(C):
❑ Portable power source; with manual activation, quick -connection receptacle and tele.metiy -
or
❑ Portable pumpingunit with plugged emergency pump connection and telemetry:
Include documentation that the portable source is owned or contracted by the applicant and is compatible with the
station.
FORM: FTA 10-23 Page 3 of 5

➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be
provided as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 4 of 5

IX. SETBACKS & SEPARATIONS = (02B .0200 & 15A NCAC.02T .0305(f)):
1. Does the project. comply with all separations/alternatives found in 15A NCAC 02T .0305(f) & (a)? Yes ❑ No
15A NCAC:02TA305(fl contains minimum separations that shall be nrovided,for sewer systems:
Setback Parameter*
Separation Required
Storm. sewers andotherutilities not listed be►ow::.(vertical)
18'inclies
2watermains (.vertical - water over sewer preferred, including id. benched trenches)
18 inches
'Water. mahvs (horizontal)
10 feet
Reclaimed water lines (vertical.- reclaimed..over sewer)
18.inches
Reclaimed waterlines (horizontal: - reclaimed -over sewer)
2.'feet.
**Any private or public ivater."supply "source, including any wells; WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100feet
**Waters classified WS (except WSJ or WS-V), B, SA, ORW, HQW, or;SB,from normal
high water (or tide- elevation) and wetlandsassociated with.these waters (see item.IX.2)
50 feet
**Any other stream, Iake,, impoundment, or ground water. lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL..
10.feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet,
Top slope of. embankment or cuts of 2 feet ;or more vertical height
10 feet
Drainage systems and interceptor drains
5feet
Any swimming pools
l0 feet
Final earth grade (vertical)
36 inches
> If noncompliance w. itli02T.0305(f). or (g),: see Section X. l of this application
*15A NCAC 02T.0305(s) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if -the ' ' se alternative.s'are used and provide narrative 'information to explain.
**Stream cassifications can be identified using the Division's NC Surface Water Classifications webnaee
2. Does this project comply with the minimum separation requirements. for water mains? ElYes ❑ No ❑ N/A
> If no„please refer to 15A NCAC 18C.0906(f) for documentation requirements "and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. ,Does the project comply. with separation requirements for wetlands? ® Yes ❑ No ❑ NIA
> Please provide supplementary information,identifying'the areas.of non-conformance.
S See the Division's draft separationreiluirements for situations where separation.cannot be met:.
No variance is required if'the- alternative design criteria specified is utilized in design :and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ :Yes Basin name: Z No
If yes,.does the project comply with setbacksformd in the river basin rules per 15A NCAC 02B .0200? ❑ Yes Q No
This includes Trout Buffered Streams per, 15A NCAC 213.0202
5. .Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes E No
or 401 Water Quality Certifications?
> Please provide the permit number/permitting status in the cover letter: if coverage/authorization is required.
6: Does project comply with. MA NCAC 02T.0105(c)(6) (additional pern-dulcertifications)? 0 Yes ❑ No
Per 15A NCAC 02T.0105(c)(6) directly related environmental permits or certification applications must be being prepared,
have been applied far, or have been obtained, Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwate'r management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes Z No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
> If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
)Nigh priority lutes shall be.inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 5 of 5

X. CERTIFICATIONS:
A. Does the:submitted sy%em,comply with. 15 A NCAC QZT-, the Minimum, Design Criteria for. the Permitting -of Pump Sta(Log
and Force Mains (latest vepjosi), and the Gravity Sewer Minimum Design. Criteria (latest version as applicable?
[9 Yes E3No
If no, for projects requiring a single variance, complete and. submit, the Variance/Alternative-Design Request application
(VADC 10-14):and supporting doctiments .for review to, the Central Office.. Approval of the request will be issued
2. ProbOssidnAl. En-gineeeg. Certification:.'
i6/0,=t57-0-tJ attest that this application for
(Professional Engineer's name from Application Item All. 1.) (Project Name fronTAPPlicatioh Item IT. 1)
has been reviewed ;by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations ' and'all other supporting documentation to the best of my knowledge.I further
attest that to the best of tryA knowledgee;proposed design has been prepared in accordance- with the applicable regulations.
Minimum besliza, Criteria' for Gravity Sewers (latest version) and the Minimum Desi2n. Criteria for the Fast-Tiitc , k
Permitting of Pumn, Stations and Fordo Mains (latest version) Although other .professionals: may have developed certain
portionsof this submittal paekagre. inclusion of these materials under my signature and seal signifies that f have reviewed :this
material have judged it to be consistent with the proposed design.
NOTE.-- In accordance with T General Statutes 143-215.6A. and 143-21,5.AB,,- any pe
statement., representation, or certification in ally application package shall be guilty
include a fine not to exceed $10.000, as.. well as civil :penalties up to.$25,000
applicationinformation,. info inatiom, including failure to disclose any design non-compliance
criteria, inhy,subJect the North Carol i.na-licensed Professional Engineer to referral to the tic
e i North Carolina Prof0i;sionAtEnginleer's seal, s. gnature,, and date:
3. ApplicanVis Certification per 15A NCAC 62T .0106(b):
rson who knowingly makes any false
ofa Class 2 misdemeanor, which in ' ay
pe
r violation. Misrepresentation of the.
with the applicable Rules and design
&hggLd. (21. NCAC 56,0701)
attest that this dpplication for 1­�(-!4we,'­4V1 L6e!�(e.:j­N6' 40­36,4,o,
(Signamw Authority Name front Application Item 13.). (Pro)ecl Name from Applic—afian item 11. 1)
attest that this application has been. reviewed. by me and is accurate and complete to the best, of my knowledge.
I understand that if all required parts of this, application are not completed and that if all required. supporting documentation
and attachments are not included, this application package is,subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters. or the land will result in an immediate enforcement
action that may include, civil penalties, injunctive relief, andlor criminal prosecution. I' will make no claim against .the
W I
Division of ater Resources should a condition of this pern-dt be violated. I also understand that if all required parts of this
application package are not completed and that if all required supporting information and attachments are not included, this
application package will be returned to me as incomplete.
NOTE - In accordance with General Statutes 143-215.6A and 143-215.6B , any person who knowingly, makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
1-1 Date: L)L�q,
P, Nl:, FOFrA 10-23 Page 6 of 5

iv
State North Carolina
Department of Environmental Quality
DWK Division of Water Resources
Division of Water Resources -/{ FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
FTA 10-23 & SUPPORTING DOCUMENTATION
Application Number: U,Wy
o,
(lobe completed by DWR)
41-K
3t.4
WJ17 (7- 24
AB items must be completed or the application
will be returned
t 3G
- '�d
2tf I ((
c
L APPLICANT INFO
1. Applicant's name( Heyworti Memorial Wesleyan Church (company, municipality, HOA, utility, etc.)
2. Applicant type: ividufll ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Brian Matherlee per 15A NCAC 02T .0106(b)
Title: Lead Pastor
4. Applicant's mailing address: 1696 Westchester Drive
City: High Poin[ State: NC Zip: 27262
5. Applicant's contact information:
Phone number: 3( 36) 882-3842 Email Address: brianmatherlee@¢mail.com
H. PROJECT INFORMATION:
1. Project name: Hayworth Wesleyan Church - Gymnasium Addition
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project ❑ ARPA funded
If a modification, provide the existing permit number: W000_ and issued date:
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: W000
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.9497' Longitude:-80.0487°
5. Parcel ID (if applicable): 6890-31-8808 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Jesse W. WilsonJ License Number: 018197
Firm: Wilson Engineering Group
Mailing address: 1001 Chestnut Drive
City: Smithfield State: NCZip: 27577-_ —
Phone number: 3( 36) 736-9267 - Email Address: [e-mail]
IV. WASTEWATER TREATMENT FACILITY (W WTF) INFORMATION:
I. Facility Name: Westside Wastewater Treatment Plant Permit Number: NCO024228
Owner Name: City of High Point
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
r
1. Permit Number(s): WQ_ ,
2. Downstream (Receiving) Sewer Information: 8 inch X Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00010 "
Owner Name(s): City of High Point
FORM: FTA 10-23 Page 1 of 5

„ VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
® Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
® School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ® Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater : 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(fl? ❑ Yes ❑ No
➢ If yes, Provide a cony of now reduction am oval letter with this aoolication
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(f))
Daily Design Flow ”
No. of Units
Flow
School
12 gal/day
127
1524 GPD
Church
5 gal/day
330
1650 GPD
Parsonage
120 gal/day
4
480GPD
gal/
GPD
gall
GPD
gall
GPD
Total
3654 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to he used as vacation rentals as defined in G.S. 42AA .
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall
be determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 3,654 GPD (per 15A NCAC 02T .0114 and G.S. 143-215.1)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 10-23 Page 2 of 5

1 VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be perttutted:
Size (inches) Length (feet) Material
➢ Section H & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VUL PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Total number of pumps at the pump station:
3. Design flow of the pump station: millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): _ gallons per minute (GPM) at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.0IC. l.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify) _
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
❑ Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the
station.
FORM: FTA 10-23 Page 3 of 5

SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T.0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T.0305(f) & (RV ❑ es ❑ No
15A NCAC 02T.0305(f) contains minimum separations that shall be provided for sewer s stems:
Setback Parameter*
Sepa ion Requir
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(f) or M. see Section X.1 of this application
*15A NCAC 02T.0305(a) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check `Yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications weboage
2. Does this project comply with the minimum separation requirements for water mains? ® fes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ED 'es []No ❑ N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: _ ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes ❑ No
➢ This includes Trout Buffered Streams per 15A NCAC 2B.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes E No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is requir
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? Yes ®No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be 'n
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ❑ Yes ® No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 10-23 Page 5 of 5

CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
N❑ Yes ❑❑ No
If no, for projects requiring a single variance, complete and submit the Variance/Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
a significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification:
I Jesse W. Wilson, P.E. I
attest that this application for Hayworth Memorial Wesleyan Church
(Professional Engineer's name from Application Item III.1.) (Project Name from Application Item II.I )
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications, engineering calculations, and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers (latest version). and the Minimum Design Criteria for the Fast -Track
Permitting of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain
portions of this submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this
material and have judged it to be consistent with the proposed design.
NOTE - In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the
application information, including failure to disclose any design non-compliance with the applicable Rules and design
criteria, may subject the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, "3yt to M Z-4ve t(� attest that this application for Hayworth Memorial Wesleyan Church
(Signature Authority Name from Application Item I.3.) (Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
I understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the
Division of Water Resources should a condition of this permit be violated. I also understand that if all required parts of this
application package are not completed and that if all required supporting information and attachments are not included, this
application package will be returned to me as incomplete.
NOTE - In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
i
Signature: Date:
i3 -Zv2
FORM: FTA 10-23 Page 10 of 5

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
Division of Water Resources (FTSE10-23)
Entity Requesting Allocation: High Point NC /
Project Nana: for which flow is being requested Hayworth Wesleyan Church -Gym addition
More than one FTSE may be r egniredfor a single project if the owner of the PVRTP is not responsiblefor all pump stations along the
route of the proposed wastewaterflow
1. Corrplete this section only ifyou are the owner of the wastewater treatment plant.
a. W WiP Facility nar e: Westside W VTP
b. W WIP Facility Pent #: WQ0024228
All flows are in MGD
c. W WTP facky's Permitted flow
10
d. Fstinated obligated flow not yet tributary to the W WTP
1.049$
e. W WTP faciVs actual average flow
3.0841 '
£ Total flow for this specific request
0.0037/
g Total actual and obligated flows to the facility
4.1376'
It Percent ofpemetted flow used
41.38%
H. Conplete this section for each ptarp station your are responsible for along the rotate ofthis proposed wastewater flow
List purrp station located between the project connection point and the W WIP.
(A) (B) (C) (D)=B+C) (F)=(A-D)
Pump Pamir Design Approx Obligated Total Current
Station Station Finn Average Daily Current Not Yet Flow Phis Available
(Naire or Pemdt Capacity, * Fbw** Avg Daily Tributary Obligated Capacity**'
Nmrber) No. MGD (Fiamrpi) Flow Daily Flow Flow MGD
MOD MGD MGD MGD
* The Ron Capacity of any pump station is defined as the maxima n pumped flow that can be
achieved with the largest purup taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor (pt)
not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located between the
project connection point and the W WTP where the Available Capacity is < 0.
DownsteamFacu7R•yNarce(Sewer): WestsideWWFP
DowmtreamPerttrit Nunber (Sewer): W00024228 `
Page 1 of 8
a-ree in )�

III. Certification Statement
I, Derrick O. Boone certify to the best ofmy knowledge that the addition of the volume of
wastewater to be penrifted in this project has been evaluated along the route to the receiving wastewater
treatment facility and that the tow fromdhis project is not anticipated to cause any capacity related sanitary
sewer overflows or overburden any downstream pump station err route to the receiving treatment plaut
under normal circumstances, given the implementation of the planned improvements identified in the
planning assessment where applicable. This analysis has been perdxcred in accordance with local
established policies and procedures using the best available data. This certification applies to those items
listed above in Sections I and II phis all attached planning assessment addendum for which I am the
responsible party. Signature ofthis form indicates acceptance of this wastewater flow.
Official Signature
M2
Title of Signing Official
ASSf f ub).G -Cz vices
lo13Ia y
Date
Page 2 of 8

Friday, September 13, 2024
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NC DcpartmEnt of
Environmental Quality
Received
OCT 1 1 M
Re: Hayworth Wesleyan (Ytlwhon-Salem
Hayworth Christian StrWbnal Office
Updated Flow Tracking for Sewer
Narrative Description
Hayworth Wesleyan Church and Hayworth Christian School is located at 1696 Westchester
Drive in High Point, North Carolina. The facility is proposing a gymnasium addition on the north
end of the church / school. The proposed gymnasium has no water or sewer proposed, however
the existing sewer laterals within the proposed gymnasium site will be relocated. With the
addition of the gymnasium, the Hayworth Christian School calculated flow rate must be
increased in accordance the Title 15A, NCAC 02T Regulations. The proposed sewer laterals will
be 4" schedule 40 PVC and constructed with a minimum fall of t/4" per linear foot in accordance
with the NC Plumbing Code. The new service laterals will discharge into an existing 6-inch PVC
sewer collection system which discharges to a municipal sewer manhole located in the cul-de-sac
of Nottingham Road.
The purpose of this Application is to provide flow data for the Flow Tracking for Sewer
Extension (FTSE) information with the City of High Point. The attached spreadsheet provides
the breakdown for all sewer flows calculated for the Hayworth facility, including the Church
(330 seats with kitchen), the School (110 Students, 17 Staff Members, Cafeteria, Gymnasium,
No Showers), and the 4 bedroom Parsonage.
School Flow: The Titlel5A, NCAC 02T Regulations are somewhat non -conclusive for a school
having a gym with no showers. In this particular instance, we see the proposed gymnasium as
more of an indoor playground replacing the outdoor basketball court. Although the school's
cafeteria is not currently being used, we used chose the 12 gal/student and included the
employees at in the total flow. The total daily sewer flow from the school is therefore calculated
at 1,524 gallons per day.
Church Flow: We included church flows (with kitchen, no daycare) at 5 gallons / seat. The total
daily sewer flow from the church side (Sunday & Wednesday Service — 330 seats) is therefore
calculated at 1,650 gallons per day.
Parsona eg Flow: The four bedroom parsonage total daily sewer flow is calculated using a
flow rate of 120 gallons per day per bedroom, for a total of 480 gallons per day.
The total sewer flow from the facility is calculated from the Wastewater Design Flow Rates
listed in 15A NCAC 02T .0114 as 3,654 gallons per day.
Sincerely,
Jesse W. Wilson, P.E.
1001 Chestnut Drive
Smithfield, North Carolina 27377
Phone [phone]

y
Hayworth Wesleyan Church Yes
Kitchen X
Daycare Center
Number of seats
Church Daily Flow Rate
Hayworth Christian School
Cafeteria X
Showers
Gymnasium X
Number of Students
Number of Staff
School Daily Flow Rate
Hayworth Parsonage
Number of Bedrooms
Parsonage Daily Flow Rate
Total Daily Flow Rate
Hayworth Wesleyan Church
Flow Tracking
No
X
X
Gallons / Seat
5
330
1,650.00
Gallons / Student / Staff
Currently no cooking or Lunch Prep
110 12
17 12
1,52
Gallons / Day / Bedroom
4 120
480.00
3,654.00

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